ECG Rhythm Interpretation

ECG Rhythm Interpretation
ECG Basics
Normal Impulse Conduction
Sinoatrial node
AV node
Bundle of His
Bundle Branches
Purkinje fibers
Impulse Conduction & the ECG
Sinoatrial node
AV node
Bundle of His
Bundle Branches
Purkinje fibers
The PQRST
P wave - Atrial
depolarization
QRS - Ventricular
depolarization
T wave - Ventricular
repolarization
The PR Interval
Atrial depolarization
+
delay in AV junction
(AV node/Bundle of His)
(delay allows time for the

atria to contract before
the ventricles contract)
Pacemakers of the Heart
SA Node - Dominant pacemaker with an

intrinsic rate of 60 - 100 beats/minute.
AV Node - Back-up pacemaker with an
intrinsic rate of 40 - 60 beats/minute.
Ventricular cells - Back-up pacemaker
with an intrinsic rate of 20 - 45 bpm.
The ECG Paper
Horizontally
One small box - 0.04 s
One large box - 0.20 s
Vertically
One large box - 0.5 mV
The ECG Paper (cont)
3 sec 3 sec
Every 3 seconds (15 large boxes) is

marked by a vertical line.
This helps when calculating the heart
rate.
NOTE: the following strips are not marked
but all are 6 seconds long.
Module II
How to Analyze a Rhythm

Rhythm Analysis
Step 1: Calculate rate.

Step 2: Determine regularity.
Step 3: Assess the P waves.
Step 4: Determine PR interval.
Step 5: Determine QRS duration.
Step 1: Calculate Rate
3 sec 3 sec
Option 1
Count the # of R waves in a 6 second rhythm
strip, then multiply by 10.
Reminder: all rhythm strips in the Modules
are 6 seconds in length.
Interpretation? 9 x 10 = 90 bpm
R wave
Option 2
Find a R wave that lands on a bold line.
Count the # of large boxes to the next R
wave. If the second R wave is 1 large box
away the rate is 300, 2 boxes - 150, 3 boxes -
100, 4 boxes - 75, etc. (cont)
3 1 1
0 5 0 7 6 5
0 0 0 5 0 0
Option 2 (cont)
Memorize the sequence:
300 - 150 - 100 - 75 - 60 - 50
Interpretation? Approx. 1 box less than

100 = 95 bpm
Step 2: Determine regularity
R R
Look at the R-R distances (using a caliper or

markings on a pen or paper).
Regular (are they equidistant apart)?
Occasionally irregular? Regularly irregular?
Irregularly irregular?
Interpretation? Regular
Step 3: Assess the P waves
Are there P waves?

Do the P waves all look alike?
Do the P waves occur at a regular rate?
Is there one P wave before each QRS?
Interpretation? Normal P waves with 1 P
wave for every QRS
Step 4: Determine PR interval
Normal: 0.12 - 0.20 seconds.

(3 - 5 boxes)
Interpretation? 0.12 seconds

Step 5: QRS duration
Normal: 0.04 - 0.12 seconds.

(1 - 3 boxes)
Interpretation? 0.08 seconds

Rhythm Summary
Rate 90-95 bpm

Regularity regular
P waves normal
PR interval 0.12 s
QRS duration 0.08 s
Interpretation? Normal Sinus Rhythm
Module III
Normal Sinus Rhythm

Normal Sinus Rhythm (NSR)
Etiology: the electrical impulse is formed

in the SA node and conducted normally.
This is the normal rhythm of the heart;
other rhythms that do not conduct via the
typical pathway are called arrhythmias.
NSR Parameters
Rate 60 - 100 bpm

Regularity regular
P waves normal
PR interval 0.12 - 0.20 s
QRS duration 0.04 - 0.12 s
Any deviation from above is sinus tachycardia,
sinus bradycardia or an arrhythmia
Arrhythmia Formation
Arrhythmias can arise from problems in

the:
Sinus node
Atrial cells
AV junction
Ventricular cells
SA Node Problems
The SA Node can:

fire too slow Sinus Bradycardia
fire too fast Sinus Tachycardia
Sinus Tachycardia may be an appropriate

response to stress.
Atrial Cell Problems
Atrial cells can:

fire occasionally Premature Atrial
from a focus Contractions (PACs)
fire continuously Atrial Flutter

due to a looping
re-entrant circuit
Teaching Moment
A re-entrant
pathway occurs
when an impulse
loops and results
in self-
perpetuating
impulse
formation.
Atrial Cell Problems
Atrial cells can also:
fire continuously Atrial Fibrillation
from multiple foci
or
fire continuously Atrial Fibrillation
due to multiple
micro re-entrant
wavelets
Teaching Moment
Atrial tissue
Multiple micro re-
entrant wavelets
refers to wandering
small areas of
activation which
generate fine chaotic
impulses. Colliding
wavelets can, in turn,
generate new foci of
activation.
AV Junctional Problems
The AV junction can:

fire continuously Paroxysmal
due to a looping Supraventricular
re-entrant circuit Tachycardia
block impulses AV Junctional Blocks
coming from the
SA Node
Ventricular Cell Problems
Ventricular cells can:

fire occasionally Premature Ventricular
from 1 or more foci Contractions (PVCs)
fire continuously Ventricular Fibrillation
from multiple foci
fire continuously
Ventricular Tachycardia
due to a looping re-
entrant circuit
Module IV a
Sinus Rhythms and

Premature Beats
Course Objectives
To recognize the normal rhythm of the

heart - Normal Sinus Rhythm.
To recognize the 13 most common
rhythm disturbances.
To recognize an acute myocardial
infarction on a 12-lead ECG.
Learning Modules
ECG Basics
Normal Sinus Rhythm
Heart Arrhythmias
Diagnosing a Myocardial Infarction
Arrhythmias
Sinus Rhythms
Premature Beats
Supraventricular Arrhythmias
Ventricular Arrhythmias
AV Junctional Blocks
Sinus Rhythms
Sinus Bradycardia
Sinus Tachycardia
Rhythm #1
Rate? 30 bpm
Regularity? regular
P waves? normal
PR interval? 0.12 s
QRS duration? 0.10 s
Interpretation? Sinus Bradycardia
Sinus Bradycardia
Deviation from NSR

- Rate < 60 bpm
Sinus Bradycardia
Etiology: SA node is depolarizing slower

than normal, impulse is conducted
normally (i.e. normal PR and QRS
interval).
Rhythm #2
Rate? 130 bpm

Regularity? regular
P waves? normal
PR interval? 0.16 s
Interpretation? Sinus Tachycardia
Sinus Tachycardia
Deviation from NSR

- Rate > 100 bpm
Sinus Tachycardia
Etiology: SA node is depolarizing faster

than normal, impulse is conducted
normally.
Remember: sinus tachycardia is a
response to physical or psychological
stress, not a primary arrhythmia.
Premature Beats
Premature Atrial Contractions

(PACs)
Premature Ventricular Contractions
(PVCs)
Rhythm #3
Rate? 70 bpm
Regularity? occasionally irreg.
P waves? 2/7 different contour
PR interval? 0.14 s (except 2/7)
Interpretation? NSR with Premature Atrial
Contractions
Deviation from NSR

These ectopic beats originate in the
atria (but not in the SA node), therefore
the contour of the P wave, the PR
interval, and the timing are different
than a normally generated pulse from
the SA node.
Etiology: Excitation of an atrial cell

forms an impulse that is then conducted
normally through the AV node and
ventricles.
Teaching Moment
When an impulse originates anywhere in

the atria (SA node, atrial cells, AV node,
Bundle of His) and then is conducted
normally through the ventricles, the QRS
will be narrow (0.04 - 0.12 s).
Rhythm #4
Rate? 60 bpm
Regularity? occasionally irreg.
P waves? none for 7th QRS
PR interval? 0.14 s
QRS duration? 0.08 s (7th wide)
Interpretation? Sinus Rhythm with 1 PVC
PVCs
Deviation from NSR

Ectopic beats originate in the ventricles
resulting in wide and bizarre QRS
complexes.
When there are more than 1 premature
beats and look alike, they are called
uniform. When they look different, they are
called multiform.
PVCs
Etiology: One or more ventricular cells

are depolarizing and the impulses are
abnormally conducting through the
ventricles.
Teaching Moment
When an impulse originates in a

ventricle, conduction through the
ventricles will be inefficient and the
QRS will be wide and bizarre.
Ventricular Conduction
Normal Abnormal
Signal moves rapidly Signal moves slowly
through the ventricles through the ventricles
Module IV b
Supraventricular and
Course Objectives

Learning Modules
ECG Basics
Normal Sinus Rhythm
Heart Arrhythmias
Advanced 12-Lead Interpretation
Arrhythmias
Sinus Rhythms
Premature Beats
Atrial Fibrillation
Atrial Flutter
Paroxysmal Supraventricular
Tachycardia
Rhythm #5
Rate? 100 bpm

Regularity? irregularly irregular
P waves? none
PR interval? none
Interpretation? Atrial Fibrillation
Atrial Fibrillation
Deviation from NSR

No organized atrial depolarization, so no
normal P waves (impulses are not
originating from the sinus node).
Atrial activity is chaotic (resulting in an
irregularly irregular rate).
Common, affects 2-4%, up to 5-10% if >
80 years old
Atrial Fibrillation
Etiology: Recent theories suggest that it

is due to multiple re-entrant wavelets
conducted between the R & L atria.
Either way, impulses are formed in a
totally unpredictable fashion. The AV
node allows some of the impulses to
pass through at variable intervals (so
rhythm is irregularly irregular).
Rhythm #6
Rate? 70 bpm
Regularity? regular
P waves? flutter waves
PR interval? none
Interpretation? Atrial Flutter
Atrial Flutter
Deviation from NSR

No P waves. Instead flutter waves
(note sawtooth pattern) are formed at
a rate of 250 - 350 bpm.
Only some impulses conduct through
the AV node (usually every other
impulse).
Atrial Flutter
Etiology: Reentrant pathway in the right

atrium with every 2nd, 3rd or 4th
impulse generating a QRS (others are
blocked in the AV node as the node
repolarizes).
Rhythm #7
Rate? 74 148 bpm

Regularity? Regular regular
P waves? Normal none
PR interval? 0.16 s none
Interpretation? Paroxysmal Supraventricular
Tachycardia (PSVT)
PSVT
Deviation from NSR

The heart rate suddenly speeds up,
often triggered by a PAC (not seen
here) and the P waves are lost.
PSVT
Etiology: There are several types of

PSVT but all originate above the
ventricles (therefore the QRS is narrow).
Most common: abnormal conduction in
the AV node (reentrant circuit looping in
the AV node).
Ventricular Fibrillation
Rhythm #8
Rate? 160 bpm

Regularity? regular
P waves? none
PR interval? none
QRS duration? wide (> 0.12 sec)
Interpretation? Ventricular Tachycardia
Deviation from NSR

Impulse is originating in the ventricles
(no P waves, wide QRS).
Etiology: There is a re-entrant pathway

looping in a ventricle (most common
cause).
Ventricular tachycardia can sometimes

generate enough cardiac output to
produce a pulse; at other times no pulse
can be felt.
Rhythm #9
Rate? none
Regularity? irregularly irreg.
P waves? none
PR interval? none
QRS duration? wide, if recognizable
Interpretation? Ventricular Fibrillation
Deviation from NSR

Completely abnormal.
Etiology: The ventricular cells are

excitable and depolarizing randomly.
Rapid drop in cardiac output and death

occurs if not quickly reversed
Course Objectives

Learning Modules
ECG Basics
Normal Sinus Rhythm
Heart Arrhythmias
Arrhythmias
Sinus Rhythms
Premature Beats
AV Nodal Blocks
1st Degree AV Block

2nd Degree AV Block, Type I
2nd Degree AV Block, Type II
3rd Degree AV Block
Rhythm #10
Rate? 60 bpm
Regularity? regular
P waves? normal
PR interval? 0.36 s
Interpretation? 1st Degree AV Block
1st Degree AV Block
Deviation from NSR

PR Interval > 0.20 s
1st Degree AV Block
Etiology: Prolonged conduction delay in

the AV node or Bundle of His.
Rhythm #11
Rate? 50 bpm
Regularity? regularly irregular
P waves? nl, but 4th no QRS
PR interval? lengthens
Interpretation? 2nd Degree AV Block, Type I
Deviation from NSR

PR interval progressively lengthens,
then the impulse is completely blocked
(P wave not followed by QRS).
Etiology: Each successive atrial impulse

encounters a longer and longer delay in
the AV node until one impulse (usually
the 3rd or 4th) fails to make it through
the AV node.
Rhythm #12
Rate? 40 bpm
Regularity? regular
P waves? nl, 2 of 3 no QRS
PR interval? 0.14 s
Interpretation? 2nd Degree AV Block, Type II
Deviation from NSR

Occasional P waves are completely
blocked (P wave not followed by QRS).
Etiology: Conduction is all or nothing

(no prolongation of PR interval);
typically block occurs in the Bundle of
His.
Rhythm #13
Rate? 40 bpm
Regularity? regular
P waves? no relation to QRS
PR interval? none
QRS duration? wide (> 0.12 s)
Interpretation? 3rd Degree AV Block
3rd Degree AV Block
Deviation from NSR

The P waves are completely blocked in
the AV junction; QRS complexes
originate independently from below the
junction.
3rd Degree AV Block
Etiology: There is complete block of

conduction in the AV junction, so the
atria and ventricles form impulses
independently of each other. Without
impulses from the atria, the ventricles
own intrinsic pacemaker kicks in at
around 30 - 45 beats/minute.
Remember
When an impulse originates in a ventricle,
conduction through the ventricles will be
inefficient and the QRS will be wide and
bizarre.
Module V
Acute Myocardial Infarction

Course Objectives

heart arrhythmias.
Learning Modules
ECG Basics
Normal Sinus Rhythm
Heart Arrhythmias
Diagnosing a MI
To diagnose a myocardial infarction you
need to go beyond looking at a rhythm
strip and obtain a 12-Lead ECG.
12-Lead
ECG
Rhythm
Strip
The 12-Lead ECG
The 12-Lead ECG sees the heart

from 12 different views.
Therefore, the 12-Lead ECG helps
you see what is happening in different
portions of the heart.
The rhythm strip is only 1 of these 12
views.
The 12-Leads
The 12-leads include:

3 Limb leads
(I, II, III)
3 Augmented leads
(aVR, aVL, aVF)
6 Precordial leads
(V1- V6)
Views of the Heart
Lateral portion
Some leads get a of the heart
good view of the:
Anterior portion
of the heart
Inferior portion
of the heart
ST Elevation
One way to
diagnose an
acute MI is to
look for
elevation of
the ST
segment.
ST Elevation (cont)
Elevation of the
ST segment
(greater than 1
small box) in 2
leads is
consistent with a
myocardial
infarction.
Anterior View of the Heart
The anterior portion of the heart is best

viewed using leads V1- V4.
Anterior Myocardial Infarction
If you see changes in leads V1 - V4

that are consistent with a myocardial
infarction, you can conclude that it is
an anterior wall myocardial infarction.
Putting it all Together
Do you think this person is having a
myocardial infarction. If so, where?
Interpretation
Yes, this person is having an acute anterior
wall myocardial infarction.
Other MI Locations
Now that you know where to look for an

anterior wall myocardial infarction lets
look at how you would determine if the MI
involves the lateral wall or the inferior wall
of the heart.
Other MI Locations
First, take a look Lateral portion
again at this of the heart
picture of the heart.
Anterior portion
of the heart
Inferior portion
of the heart
Other MI Locations
Second, remember that the 12-leads of the ECG look at different
portions of the heart. The limb and augmented leads see
electrical activity moving inferiorly (II, III and aVF), to the left (I,
aVL) and to the right (aVR). Whereas, the precordial leads see
electrical activity in the posterior to anterior direction.
Limb Leads Augmented Leads Precordial Leads

Other MI Locations
Now, using these 3 diagrams lets figure where
to look for a lateral wall and inferior wall MI.
Anterior MI
Remember the anterior portion of the heart is
best viewed using leads V1- V4.
Lateral MI
So what leads do you think
the lateral portion of the Leads I, aVL, and V5- V6
heart is best viewed?

Inferior MI
Now how about the inferior
portion of the heart? Leads II, III and aVF

Now, where do you think this person is
having a myocardial infarction?
Inferior Wall MI
This is an inferior MI. Note the ST elevation
in leads II, III and aVF.
How about now?
Anterolateral MI
This persons MI involves both the anterior wall
(V2-V4) and the lateral wall (V5-V6, I, and aVL)!
Course Objectives

heart arrhythmias.
Learning Modules
ECG Basics
Normal Sinus Rhythm
Heart Arrhythmias
The 12-Lead ECG
The 12-Lead ECG contains a wealth of

information. In Module V you learned that
ST segment elevation in two leads is
suggestive of an acute myocardial
infarction. In this module we will cover:
ST Elevation and non-ST Elevation MIs
Left Ventricular Hypertrophy
Bundle Branch Blocks
ST Elevation and
non-ST Elevation MIs
ST Elevation and non-ST Elevation MIs
When myocardial blood supply is abruptly
reduced or cut off to a region of the heart, a
sequence of injurious events occur beginning
with ischemia (inadequate tissue perfusion),
followed by necrosis (infarction), and eventual
fibrosis (scarring) if the blood supply isn't
restored in an appropriate period of time.
The ECG changes over time with each of

these events
ECG Changes
Ways the ECG can change include:
ST elevation &
depression
T-waves
peaked flattened
Appearance inverted
of pathologic
Q-waves
ECG Changes & the Evolving MI
Non-ST Elevation
There are two
distinct patterns
of ECG change
depending if the
infarction is: ST Elevation
ST Elevation (Transmural or Q-wave), or

Non-ST Elevation (Subendocardial or non-Q-wave)
ST Elevation Infarction
The ECG changes seen with a ST elevation infarction are:
Before injury Normal ECG
Ischemia ST depression, peaked T-waves, then T-wave

inversion
Infarction ST elevation & appearance of

Q-waves
Fibrosis ST segments and T-waves return to
normal, but Q-waves persist
Heres a diagram depicting an evolving infarction:
A. Normal ECG prior to MI
B. Ischemia from coronary artery occlusion

results in ST depression (not shown) and
peaked T-waves
C. Infarction from ongoing ischemia results in

marked ST elevation
D/E. Ongoing infarction with appearance of

pathologic Q-waves and T-wave inversion
F. Fibrosis (months later) with persistent Q-

waves, but normal ST segment and T-
waves
Heres an ECG of an inferior MI:
Look at the
inferior leads
(II, III, aVF).
Question:
What ECG
changes do
you see?
ST elevation
and Q-waves
Extra credit:
What is the
rhythm? Atrial fibrillation (irregularly irregular with narrow QRS)!
Non-ST Elevation Infarction
Heres an ECG of an inferior MI later in time:
Now what do
you see in the
inferior leads?
ST elevation,
Q-waves and
T-wave
inversion
The ECG changes seen with a non-ST elevation infarction are:
Before injury Normal ECG
Ischemia ST depression & T-wave inversion
Infarction ST depression & T-wave inversion
Fibrosis ST returns to baseline, but T-wave

inversion persists
Heres an ECG of an evolving non-ST elevation MI:
Note the ST
depression
and T-wave
inversion in
leads V2-V6.
Question:
What area of
the heart is
infarcting?
Anterolateral
Compare these two 12-lead ECGs. What stands
out as different with the second one?
Normal Left Ventricular Hypertrophy
Answer: The QRS complexes are very tall

(increased voltage)
Why is left ventricular hypertrophy characterized by tall
QRS complexes?
As the heart muscle wall thickens there is an increase in
electrical forces moving through the myocardium resulting
in increased QRS voltage.
LVH ECHOcardiogram
Increased QRS voltage
Criteria exists to diagnose LVH using a 12-lead ECG.
For example:
The R wave in V5 or V6 plus the S wave in V1 or V2
exceeds 35 mm.
However, for now, all

you need to know is
that the QRS voltage
increases with LVH.
Turning our attention to bundle branch blocks
Remember normal
impulse conduction is
SA node
AV node
Bundle of His
Bundle Branches
Purkinje fibers
Normal Impulse Conduction
Sinoatrial node
AV node
Bundle of His
Bundle Branches
Purkinje fibers
So, depolarization of
the Bundle Branches
and Purkinje fibers are
seen as the QRS
complex on the ECG.
Therefore, a conduction
block of the Bundle
Branches would be Right
reflected as a change in BBB
the QRS complex.
With Bundle Branch Blocks you will see two changes
on the ECG.
1. QRS complex widens (> 0.12 sec).
2. QRS morphology changes (varies depending on ECG lead,
and if it is a right vs. left bundle branch block).
Why does the QRS complex widen?
When the conduction

pathway is blocked it
will take longer for
the electrical signal
to pass throughout
the ventricles.
Right Bundle Branch Blocks
What QRS morphology is characteristic?
For RBBB the wide QRS complex assumes a
unique, virtually diagnostic shape in those
leads overlying the right ventricle (V1 and V2).
V1
Rabbit Ears
Left Bundle Branch Blocks
What QRS morphology is characteristic?
For LBBB the wide QRS complex assumes a
characteristic change in shape in those leads
opposite the left ventricle (right ventricular
leads - V1 and V2).
Broad,
Normal deep S
waves
Summary
This Module introduced you to:
ST Elevation and Non-ST Elevation MIs
Dont worry too much right now about trying to

remember all the details. Youll focus more on
advanced ECG interpretation in your clinical
years!
Course Objective
To systematically analyze a 12-lead

ECG.
Reading 12-Lead ECGs
The 12-Lead ECG contains information that will assist
you in making diagnostic and treatment decisions in your
clinical practice. In previous modules you learned how to
read and interpret parts of the ECG. Now, we will bring all
that you have learned together so that you can
systematically read and interpret a 12-lead ECG.
The information will be divided into two modules, VII a

and VII b.
The best way to read 12-lead ECGs is to develop a step-
by-step approach (just as we did for analyzing a rhythm
strip). In these modules we present a 6-step approach:
1. Calculate RATE
2. Determine RHYTHM
3. Determine QRS AXIS
4. Calculate INTERVALS
5. Assess for HYPERTROPHY
6. Look for evidence of INFARCTION
Rate Rhythm Axis Intervals Hypertrophy Infarct
In Module II you learned how to calculate the

rate. If you need a refresher return to that module.
There is one new thing to keep in mind when

determining the rate in a 12-lead ECG
If you use the rhythm

strip portion of the
12-lead ECG the total
length of it is always
10 seconds long. So
you can count the
number of R waves
in the rhythm strip
and multiply by 6 to
determine the beats Rate? 12 (R waves) x 6 = 72 bpm
per minute.
In Module II you learned how to systematically

analyze a rhythm by looking at the rate, regularity,
P waves, PR interval and QRS complexes.
In Modules III, IV and V you learned how to

recognize Normal Sinus Rhythm and the 13 most
common rhythm disturbances.
If you need a refresher return to these modules.

Tip: the rhythm strip portion of the 12-lead ECG is a good

place to look at when trying to determine the rhythm
because the 12 leads only capture a few beats.
Rhythm?
Atrial
1 of 12 leads fibrillation
Lead II
Rhythm strip
Axis refers to the mean QRS axis (or vector) during ventricular
depolarization. As you recall when the ventricles depolarize (in a
normal heart) the direction of current flows leftward and downward
because most of the ventricular mass is in the left ventricle. We like
to know the QRS axis because an abnormal axis can suggest
disease such as pulmonary hypertension from a pulmonary
embolism.
The QRS axis is determined by overlying a circle, in the frontal
plane. By convention, the degrees of the circle are as shown.
The normal QRS axis lies between -30o and +90o.
A QRS axis that falls between -30o -90o
and -90o is abnormal and called left -120o -60o
axis deviation.
-150o -30o
A QRS axis that falls between +90o
and +150o is abnormal and called 180o 0o
right axis deviation.
150o 30o
A QRS axis that falls between +150o
and -90o is abnormal and called
60o
superior right axis deviation. 120o
90o
We can quickly determine whether the QRS axis is

normal by looking at leads I and II.
QRS negative (R < Q+S)
If the QRS complex is
overall positive (R > Q+S)
in leads I and II, the QRS
axis is normal.
In this ECG what leads

have QRS complexes
that are negative?
equivocal?
QRS equivocal (R = Q+S)
How do we know the axis is normal when the QRS

complexes are positive in leads I and II?
The answer lies in the fact that each frontal lead

corresponds to a location on the circle.
Limb leads
-90o
I = +0o -120o -60o
II = +60o avR -150o -30o avL
III = +120o
Augmented leads
180o 0o II
avL = -30o 30o
150o
avF = +90o
60o
avR = -150 o 120o
III 90o II II
avF
Since lead I is orientated at 0o a wave of depolarization directed towards
it will result in a positive QRS axis. Therefore any mean QRS vector
between -90o and +90o will be positive.
-90o
-120o -60o
-150o -30o
180o 0o I
150o 30o
o 60o
120
90o
Similarly, since lead II is orientated at 60o -90o
a wave of depolarization directed towards -120o -60o
it will result in a positive QRS axis.
-150o -30o
Therefore any mean QRS vector between
-30o and +150o will be positive.
180o 0o I
150o 30o
o 60o
120
90o
II
Similarly, since lead II is orientated at 60o -90o
a wave of depolarization directed towards -120o -60o
it will result in a positive QRS axis.
-150o -30o
Therefore any mean QRS vector between
-30o and +150o will be positive.
180o 0o I
Therefore, if the QRS complex is positive
in both leads I and II the QRS axis must 150o 30o
be between -30o and 90o (where leads I
and II overlap) and, as a result, the axis 60o
120o
must be normal. 90o
II
Now using what you just learned fill in the following table. For example, if
the QRS is positive in lead I and negative in lead II what is the QRS axis?
(normal, left, right or right superior axis deviation)
QRS Complexes -90o
I II Axis -120o -60o
+ + normal -150o -30o

+ - left axis deviation
180o 0o I
150o 30o
o 60o
120
90o
II
if the QRS is negative in lead I and positive in lead II what is the QRS
axis? (normal, left, right or right superior axis deviation)
QRS Complexes -90o

+ + normal -150o -30o

- + right axis deviation 180o 0o I
150o 30o
o 60o
120
90o
II
if the QRS is negative in lead I and negative in lead II what is the QRS
axis? (normal, left, right or right superior axis deviation)
QRS Complexes -90o

+ + normal -150o -30o

- + right axis deviation 180o 0o I
- - right superior 150o 30o

axis deviation
o 60o
120
90o
II
Is the QRS axis normal in this ECG? No, there is left axis
deviation.
The QRS is
positive in I
and negative
in II.
To summarize:
The normal QRS axis falls between -30o and +90o because ventricular
depolarization is leftward and downward.
Left axis deviation occurs when the axis falls between -30o and -90o.
Right axis deviation occurs when the axis falls between +90o and +150o.
Right superior axis deviation occurs when the axis falls between between
+150o and -90o.
A quick way to determine QRS Complexes
the QRS I II Axis
axis is to look at the QRS + + normal
complexes in leads I and II. + - left axis deviation
- + right axis deviation
- - right superior
axis deviation
SUMMARY Rate Rhythm Axis Intervals Hypertrophy Infarct
To summarize VII a:
1. Calculate RATE
2. Determine RHYTHM
Normal
Left axis deviation
Right axis deviation
Right superior axis deviation
In VII b we will cover the next 3 steps:

1. Calculate RATE
2. Determine RHYTHM
Course Objective
To systematically analyze a 12-lead

ECG.
In Module VII a we introduced a 6 step approach for
analyzing a 12-lead ECG and covered the first 3 steps. In
this module we will cover the last 3 steps.
1. Calculate RATE
2. Determine RHYTHM
Intervals refers to the length of the PR and QT intervals
and the width of the QRS complexes. You should have
already determined the PR and QRS during the rhythm
step, but if not, do so in this step.
In the following few slides well review what is a normal

and abnormal PR, QRS and QT interval. Also listed are a
few common causes of abnormal intervals.
PR interval
< 0.12 s 0.12-0.20 s > 0.20 s
High catecholamine
states Normal AV nodal blocks
Wolff-Parkinson-White
Wolff-Parkinson-White 1st Degree AV Block

QRS complex
< 0.10 s 0.10-0.12 s > 0.12 s
Bundle branch block

Incomplete bundle
Normal PVC
branch block
Ventricular rhythm
Incomplete bundle branch block 3rd degree AV block with

ventricular escape rhythm
Remember: If you have a BBB determine if it is a right or left

BBB. If you need a refresher see Module VI.
QT interval
The duration of the QT interval is
proportionate to the heart rate. The faster
the heart beats, the faster the ventricles
repolarize so the shorter the QT interval.
Therefore what is a normal QT varies
with the heart rate. For each heart rate you
need to calculate an adjusted QT interval,
called the corrected QT (QTc):
QTc = QT / square root of RR interval
QTc interval
< 0.44 s > 0.44 s Long QT
Normal Long QT
Torsades de Pointes
A prolonged QT can be very dangerous. It may predispose an individual to a type of

ventricular tachycardia called Torsades de Pointes. Causes include drugs, electrolyte
abnormalities, CNS disease, post-MI, and congenital heart disease.
QT = 0.40 s
RR = 0.68 s
Square root of
RR = 0.82
QTc = 0.40/0.82
= 0.49 s
PR interval? QRS width? QTc interval?

0.16 seconds 0.08 seconds 0.49 seconds
Interpretation of intervals? Normal PR and QRS, long QT
RR
23 boxes 17 boxes
10 boxes 13 boxes
QT
Normal QT Long QT
Tip: Instead of calculating the QTc, a quick way to estimate if the

QT interval long is to use the following rule:
A QT > half of the RR interval is probably long.
In this step of the 12-lead ECG analysis, we use the ECG

to determine if any of the 4 chambers of the heart are
enlarged or hypertrophied. We want to determine if there
are any of the following:
Right atrial enlargement (RAE)
Left atrial enlargement (LAE)
Right ventricular hypertrophy (RVH)
Left ventricular hypertrophy (LVH)
In Module VI we introduced the concept of left ventricular
hypertrophy. As you remember the QRS voltage increases with LVH
and is characterized by tall QRS complexes in certain leads. Similarly
for right ventricular hypertrophy we look at the QRS complexes for
changes in voltage patterns.
With right and left atrial enlargement we analyze the P wave (since
the P wave represents atrial depolarization). Here we also look for
changes in voltage patterns.
Note: as mentioned in Module VI criteria exists to diagnose LVH,

the same goes for RAE, LAE and RVH. In the following slides we will
be presenting criteria you can use. However other criteria exists and
as a reference you might find it useful to carry a copy of Tom Evans
ECG Interpretation Cribsheet.
Right atrial enlargement

Take a look at this ECG. What do you notice about the P waves?
The P waves are tall, especially in leads II, III and avF.
Ouch! They would hurt to sit on!!
Right atrial enlargement

To diagnose RAE you can use the following criteria:
II P > 2.5 mm, or
V1 or V2 > 1 boxes (in height)
P > 1.5 mm
Remember 1 small
> 2 boxes (in height)
box in height = 1 mm
A cause of RAE is RVH from pulmonary hypertension.

Left atrial enlargement

Take a look at this ECG. What do you notice about the P waves?
Notched
Negative deflection
The P waves in lead II are notched and in lead V1 they

have a deep and wide negative component.
Left atrial enlargement

To diagnose LAE you can use the following criteria:
II > 0.04 s (1 box) between notched peaks, or
V1 Neg. deflection > 1 box wide x 1 box deep
Normal LAE
A common cause of LAE is LVH from hypertension.
Right ventricular hypertrophy

Take a look at this ECG. What do you notice about the axis and QRS
complexes over the right ventricle (V1, V2)?
There is right axis deviation (negative in I, positive in II) and

there are tall R waves in V1, V2.

Compare the R waves in V1, V2 from a normal ECG and one from a
person with RVH.
Notice the R wave is normally small in V1, V2 because the right
ventricle does not have a lot of muscle mass.
But in the hypertrophied right ventricle the R wave is tall in V1, V2.
Normal RVH

To diagnose RVH you can use the following criteria:
Right axis deviation, and
V1 R wave > 7mm tall
A common
cause of RVH
is left heart
failure.
Left ventricular hypertrophy

Take a look at this ECG. What do you notice about the axis and QRS
complexes over the left ventricle (V5, V6) and right ventricle (V1, V2)?
The deep S waves

seen in the leads over
the right ventricle are
created because the
heart is depolarizing
left, superior and
posterior (away from
leads V1, V2).
There is left axis deviation (positive in I, negative in II) and there

are tall R waves in V5, V6 and deep S waves in V1, V2.
Left ventricular hypertrophy

To diagnose LVH you can use the following criteria*:
R in V5 (or V6) + S in V1 (or V2) > 35 mm, or
avL R > 13 mm
S = 13 mm
* There are several
other criteria for the
diagnosis of LVH.
R = 25 mm
A common cause of LVH
is hypertension.
A 63 yo man has longstanding, uncontrolled hypertension. Is there evidence of heart
disease from his hypertension? (Hint: There a 3 abnormalities.)
Yes, there is left axis deviation (positive in I, negative in II), left atrial enlargement
(> 1 x 1 boxes in V1) and LVH (R in V5 = 27 + S in V2 = 10 > 35 mm).
When analyzing a 12-lead ECG for evidence of an infarction
you want to look for the following:
Abnormal Q waves
ST elevation or depression
Peaked, flat or inverted T waves
These topics were covered in Modules V and VI where you

learned:
ST elevation (or depression) of 1 mm in 2 or more contiguous
leads is consistent with an AMI
There are ST elevation (Q-wave) and non-ST elevation (non-Q
wave) MIs
Tip: One way to determine if Q waves (and R waves) are abnormal is by looking at the
width and using the following mantra (read red downwards):
Any Any Q wave in V1
20 A Q wave > 20 msec in V4 (i.e. 0.02 sec or width of a box)

30 A Q wave > 30 msec in V5
30 A Q wave > 30 msec in V6
30 A Q wave > 30 msec in I

30 A Q wave > 30 msec in avL
30 A Q wave > 30 msec in II
30 A Q wave > 30 msec in avF
R40 A R wave > 40 msec in V1

R50 A R wave > 50 msec in V2
This mantra corresponds to the ECG in the following way:

30 Any R40 20
30 30 Any R50 30
30 Any 30
To summarize:
1. Calculate RATE
2. Determine RHYTHM
Normal
Left axis deviation
Right axis deviation
Right superior axis deviation
To summarize:
1. Calculate RATE
2. Determine RHYTHM
PR
QRS
QT
To summarize:
1. Calculate RATE
2. Determine RHYTHM
Right and left atrial enlargement
Right and left ventricular hypertrophy
To summarize:
1. Calculate RATE
2. Determine RHYTHM
Abnormal Q waves
ST elevation or depression
Peaked, flat or inverted T waves
To summarize:
1. Calculate RATE
2. Determine RHYTHM
Now to finish this module lets analyze a 12-lead ECG!

A 16 yo young man ran into a guardrail while riding a motorcycle.
In the ED he is comatose and dyspneic. This is his ECG.
What is the rate? Approx. 132 bpm (22 R waves x 6)
What is the rhythm? Sinus tachycardia
What is the QRS axis? Right axis deviation (- in I, + in II)
What are the PR, QRS PR = 0.12 s, QRS = 0.08 s, QTc = 0.482 s
and QT intervals?
Is there evidence of No (no peaked, notched or negatively
atrial enlargement? deflected P waves)
Is there evidence of No (no tall R waves in V1/V2 or V5/V6)
ventricular hypertrophy?
Infarct: Are there abnormal Yes! In leads V1-V6 and I, avL
Q waves?
30 Any R40 20
30 30 Any R50 30
30
Any 30
Infarct: Is the ST elevation Yes! Elevation in V2-V6, I and avL.
or depression? Depression in II, III and avF.
Infarct: Are there T wave No
changes?
ECG analysis: Sinus tachycardia at 132 bpm, right axis deviation,
long QT, and evidence of ST elevation infarction in the
anterolateral leads (V1-V6, I, avL) with reciprocal changes (the
ST depression) in the inferior leads (II, III, avF).
This young man suffered an
acute myocardial infarction after
blunt trauma. An
echocardiogram showed
anteroseptal akinesia in the left
ventricle with severely
depressed LV function
(EF=28%). An angiogram
showed total occlusion in the
proximal LAD with collaterals
from the RCA and LCX.

ECG Rhythm Interpretation

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ECG Rhythm Interpretation

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ECG Rhythm Interpretation

(delay allows time for the

SA Node - Dominant pacemaker with an

Every 3 seconds (15 large boxes) is

How to Analyze a Rhythm

Step 1: Calculate rate.

Interpretation? Approx. 1 box less than

Look at the R-R distances (using a caliper or

Are there P waves?

Normal: 0.12 - 0.20 seconds.

Interpretation? 0.12 seconds

Normal: 0.04 - 0.12 seconds.

Interpretation? 0.08 seconds

Rate 90-95 bpm

Normal Sinus Rhythm

Etiology: the electrical impulse is formed

Rate 60 - 100 bpm

Arrhythmias can arise from problems in

The SA Node can:

Sinus Tachycardia may be an appropriate

Atrial cells can:

fire continuously Atrial Flutter

The AV junction can:

Ventricular cells can:

Sinus Rhythms and

To recognize the normal rhythm of the

Deviation from NSR

Etiology: SA node is depolarizing slower

Rate? 130 bpm

Deviation from NSR

Etiology: SA node is depolarizing faster

Premature Atrial Contractions

Deviation from NSR

Etiology: Excitation of an atrial cell

When an impulse originates anywhere in

Deviation from NSR

Etiology: One or more ventricular cells

When an impulse originates in a

To recognize the normal rhythm of the

Rate? 100 bpm

Deviation from NSR

Etiology: Recent theories suggest that it

Deviation from NSR

Etiology: Reentrant pathway in the right

Rate? 74 148 bpm

Deviation from NSR

Etiology: There are several types of

Rate? 160 bpm

Deviation from NSR

Etiology: There is a re-entrant pathway

Ventricular tachycardia can sometimes

Deviation from NSR

Etiology: The ventricular cells are

Rapid drop in cardiac output and death

To recognize the normal rhythm of the

1st Degree AV Block

Deviation from NSR

Etiology: Prolonged conduction delay in

Deviation from NSR

Etiology: Each successive atrial impulse

Deviation from NSR

Etiology: Conduction is all or nothing

Deviation from NSR